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31146 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO ' BUILDING-ELECTRICAL PERMITNO. /� lg BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. " - 3 [F BUILDING PROJECTIDENTIFICATION BUILIIINGAODRESS: SANITARY NO. APPLICATION SUBMITTAL DATE 22_5155 Kt Aj sr E , M'S NAME: ^ ,� 1{ �' t CONIRACTOR'S NAME: LIC NO: JTJV� N/C ( CONTROL p 10hCHITECT/ENGINEER: LIC NO: ADDRESS: ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ CBRSBItaBi Fees Paid 6y Applicant(Initial) p1,DG I?CECT PLUMB" "MECH LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE •ITT,[T ❑ ❑ G C Z I hereby affirm that I am'licensed under previsions of Chapter 9(commencing JOB DESCRIPTION F30with Section 7000)of Division 3 of the Business and Profession,Crate,and my license is ad _ PERMIT ISSUANCE RESIDENTIAL: :^ n full force and effect. �U� License Class Lica ❑SFDWI. ❑KITCHEPLUMBIINREMODEL ((�� APPLIANCES_-RESIUENTIAI. Dam Connector ❑ADDITION ❑PLUMBING RF.PIPE ARCHITECT'S DECLARATION - ❑MULTFUNIT ❑STRUCTURAL. Font lundersmalm 1 PANF;IIS Zpoe my shell be'usea as public recoNs - t�f� MODIFICATION O 2_- 0 UPT0200 AA1P$ `47L/ ❑INTERIOR [I CHIMNEY REPAIR Licensed Prf:Tonal I 201-1000AMPS - - IMPROVEMENT 2 OWNTR BUILDEk DECLARATION Q 1 h reby affirm that I am Romp(stun the Comrmto L se Law for the OVER Ifg0AMP5 a ❑BATH REM 1/REP ❑DEty101.ITION 3 4 U fulln t 6 re: n.(Sect 4dil'S Business and Profess ons Code:Any city or muntY SIGNS ELECTRICAL 11 OTHER e,�,� ti which requires.'permit to convect,ober,improve,demolish or repair any suuctare ��yDA prior to its issuance,also requires the applicant for such Permit o file.signed smicmem SPECIALCIItCUIT/MISC.' - teSyQ the he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 apo (commeni di Seeded land of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: 4 n oC that he is exempt therefrom and the this for the alleged exemption.Any violutinn of ❑NEW BLDG/ADDITION 0 DEMOLITION -,m Section 7031.5 by any applicant fora permit suhjoets the applicant to a civil penalty of POWER DEVICES ` k, to not marc than five hundred dollars($50d, ❑TENANT [I FOOD SERVICF, 6 El 1,as owner of the property,ler my employees with wages as(heirsole cnmpensminn, SWIMMING POOL ELECTRIC IMPROVEMENT 4 villdothe work,and rheawmurc is nolimeWed oroffe¢J for sale(Sa.]644,Business —s ❑OTHER a3 and E'rofessime,Code:The Contractors License Law Joos not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who hi ilda or impnwea themon,and who does such work himself,through his own employees,provided that such improvements are not intended or offered for ' NEW RESIDENHAL ELECTR SQ FT. sale.lLhowever,the building or improvement is sold within one yearof rompleisin,the - SQ.PI'. RA $/SQ.FT enhuildaF will have the harden of proving that he did not build or improve for per- - pose of xale.). ❑1,as owner of the property,am exclusively convecting with licensetl contraction to MAR ^8 RLCT unsure rhe project(Sem.7044,Business and Prnfessimms CiateU The CanrractnOx LI- ,, cense law does not apply to an owner of Pauli who Milds or improves thereon,and QTY, PLUMBING PERMIT FEE as Who contracts for such projects with a mnwaor(s)licensed pursuant to the Commemr's _ License caw- CIIY V( Vvf Lrrlllvl I em a rep under Sec. ,B&P for tai PERMIT ISSUANCE .Owner 74. ` Date - ALTER-DRAIN&VI?NT-WATER(I?A1 VALUATION WORKER'S COMPHNAdIO0 DECLARATION BACK FLOW,PROTECT.DEVICE It [hereby affimt under Penalty of perjury one of the following declomtions: l have and will maintain a Certificate ofConseen m hell'-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND, GRIPS TYPE CONSTRUCTION cation,as provided far by Section 37M of the Labor Code,for the yerlormance of the work for which this permit is issued FIXTURES-PCR TRAP ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 37M of the Labor Code,for the performance of the work for which this permit is issued. 'GAS-EA.SYSTEM-1 INC.4 OUTLETS "" i CarriOCC.GROUP AI'N Ca Worker's Compensation Insurance nnce carrier Policy number are: er. Policy No.: GAS-fvS.SYSTfiM�OVER4(I'A) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE _ GREASWINDUSTRL WASTE INTERCEPTOR t ' (ThissationneednatbecomploMifNc mitisforonehundmldollma(SI00) BUILDING DIVISION FEES orless,) GREASI?TRAP _ PIANCIIECK PEE Icenify that inthe any simmer mmrof theworkfor whichNis permhisissued,'Comhel SEWER SANITARY-STORM EA. FT. not employ any person in any manner ur asnbecome subject it) Workers'Camper- ENERGY FEE ' OZ smion Laws o1 California.Date, WATER HEYIER W/VENTMLECTR _ _ Z �, Applicant GRADING FEE y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSHMOREATING - abecome subject to the Worker's Compensation provisions of the Labor GNe,you mom _ SOILS FEE C forthwith comply with such provisions nr this permit shall be deemed revoked. WATER SERVICE Q Uz CONSemisa construction agent' h NEW RESIDENTIAL PCMB. SQ 1q. PAID 'l thereby ffi Data ReceiptM W. O ri toe Pe them issued Sce,3097.Cis.agency for the Performance of W. F"t the Work for which this Permit is i.mW(Sa.1(00].Civ.CJ U Lender's Name _ TOTAL: 4tl sLender'I Address TOI'AI.: 4 Icenify Thar 1 have read this application mat smm that the above information is - BUILDING HE y correct.1 agree to comply with all city and county ordin.nces and nae laws rearing to' QTY, MECHANICAL PERMIT FEE V Z huildingeoraswcdon,and herehyamaoriee representatives ofthiscirym toleration the SEISMIC FEE '-' above-mentioned property for inspection prrpn,ex. . ' . PFRMII ISSUANCE (We)agree to save,indemnify..it keep h oddeas Ilia City of Cupertino against ELECTRIC FEE Iiabilities,judgrncros,cnsrs add expenses which may in any wayaccrusit,inst said City ALTER OR ADD TO MECH. PLUMBING FEE in ennaeq mace mf the gran,n,of this permit. APPLIC - UNDERST'ANDS/q)ND LL COMPLY WITH ALI NONROINT AIR HANDLING UN1TOOl0,00BCFM) MECHANICAL FEE, SOUR( .R GULADONS,._v`s . _ 1 �� � AIR HANDLING UNE I'(OVER I(l,fgO CFM) CONSTRUCTION TA% Signature of ApplicaniConrmeor Um EXHAUST GOOD(W/DUCT) HOUSING MITIGATION FEF. HAZARDOUS MATER SDISCLOSUR: Will theapplicant or future building oecupam siort or handle hmardous material HEATING UNIT TIO 1110,000 BTU) as defined by the Cupertino Municipal Gate,Chapter 912,and the Health and Safety Code,Section 25532(x)? HEATING UNIT(OVER RA000 BTU) ❑Yes ❑No VENTILATION PAN(SINGLE RES ED) PAID. Will the applicant or future building compare use equipment or devices which .. - Data Receipt N mu hmaNaus an examaninanu as defined by the Bay Arc.Air Quality Management BOILER-COMP UHP OR 100,000 BTU) Distrix? TOTAL: E]yes F1 No BOILER-COMP(OVER 100.006BTU) Ihre mad llot ha d ' a a0,1i. ' n I alar Ch ne,6.95 of the Cei- AIR CONDITIONF.k t„ IS. ANCE DA mean c th&Safey CukS n537 nit 255341 .vend ma if the NF.W RESIDENTIAL MECH SQ,PI.l ' gat smm cuwndyhoe et my reTonsibiltyt ! fy thea pareequ cots which fiCcti lit�te d-ffyp i l Done,nr authorized agent - Dm ,} TOTAL: ISSUED BY: OFFICE -mq agelS Io aouewpl0 40 hue It Hold Ilue ;o umlgla;n ay{ ;o lenoldde���. Im I aq of >o 1;auad of p:ay aq ION 11VH$ �1 �X.If-n sur)gen;pads pug umd s!tp to Bu;dwels ayl (� ouq edn0 ;o Ap! "IdaO 2u!p!;nq ay; wo{{{ tmissu!ad a;".:�n ;noyl!:u awes uo svoLalte ,o sa`uzu^ :Wu ayew of 11pal Ii't, It. uo�s; l?pug ra,rl 1`.e '"' rol ayl uo ldaH q / _ Y STU ��r1el! �_/i2C u�� L$II'il SUGgg ' :dads ON sug'd 10 las s. 1 7Gf SnNt� EtLr. p ; 7 y(� 7)0 lJ3N Ic� �i l/o ll r 2V.4 C-+F:. 311 3'J!6'.VNION0 ONV S3000 ONI183d0 ;{ 4tIO 3Hi H11M 30NVO8000V NI v n7n^yam-1� I L 't G 1 O �n �oSN-/�'Rlo/L c 1 LCEa,r; a' / pl"v('psr o �v dolp S�s31�,1.ICt �D _ �_ �l/ �� C�lL� rl� ��/� frtilST/r1�t r'iln.rl- l�d�[. � CUM � �r G u l�rel c Z� � mP MA11,1 MAR 2 8 1997 A dE W/ i CY,511,J4 too AMO, zmov P3tzb4Kr7 © �cent�rr., <.x,sn�tc, 5�JRP,4xj 4e2vtcunly E,JT 1r� UG.INSPECTION DEPARTMENT ----------- - - Hc0t.v- 4A ¢,taE CITY OF CUPERTINO _ --------_._---- OFFICE OrY owrlt t< G'OILDEk ^ !/� �v71 ! �lti(e 22-5S5$ Ki rJsT C-T- l CvPc. / / lAl() / lel n-(D QCSIAC/vi n,not s tuvuow o • i".v n OV